History

Phobic disorders can be disabling and cause severe emotional distress, leading to other anxiety disorders, depression, suicidal ideation, and substance-related disorders, especially alcohol abuse or dependence. The physician must inquire about these areas as well.

Inquire about the amount of caffeine intake (including coffee, caffeinated teas, or sodas). Considering the overall noradrenergic hyperdrive of this group of patients, even moderate amounts of coffee might exacerbate the anxiety response and symptoms.

If social anxiety disorder (social phobia) is suspected, ask the patient about any difficulties in social situations, such as speaking in public, eating in a restaurant, or using public washrooms. Fear of scrutiny by others or of being embarrassed or humiliated is commonly described by people with this disorder.

If a specific phobia is suspected, ask about irrational and out-of-proportion fear or avoidance of particular objects or situations (eg, animals, insects, blood, needles, flying, or heights). Assess intensity and course of fear.

If agoraphobia is suspected, inquire about any intense anxiety and avoidance of the feared object/situation following exposure to specific situations such as heights, animals, small spaces, or storms. Other areas of inquiry should include fear of being trapped without escape (eg, being outside the home and alone, in a crowd of unfamiliar people, on a bridge, in a tunnel, or in a moving vehicle).

Physical Examination

Anxiety is the most common feature in phobic disorders. Manifestations include the following (all of which should be asked about and assessed):

Sweating
Palpitations
Elevated blood pressure
Elevated heart rate
Dyspnea
Dizziness
Tremor
Diarrhea
Paresthesias

Because anxiety manifests with a number of physical symptoms, any patient who presents with a de novo complaint of physical symptoms suggestive of an anxiety disorder should undergo a physical examination to help rule out medical conditions that might present with anxietylike symptoms (see Differentials). If a patient presents for a repeat visit with similar complaints, after medical contributors have been ruled out, a careful mental status examination might be preferable to repeat physical examination and laboratory investigations.

When considering anxiety as the primary suspect, the physician should always remember that over time, patients with anxiety are just as likely to develop medical conditions as other patients are. Accordingly, a diagnosis of anxiety, though changing the threshold for investigation of physical symptoms, should not keep the patient from receiving regular follow-up examinations as otherwise indicated.

More than 75% of patients with blood-injection-injury type phobia report a history of fainting in situations where they are presented with a trigger. Initial increases in heart rate and blood pressure are followed by decreases in both parameters, resulting in fainting. This physiologic response differs from the typical response seen in other phobias, in which exposure is followed by increased heart rate and blood pressure.^[1]

Mental status examination

The physician should assess the patient’s appearance, behavior, ability to cooperate with the examination, level of activity, speech, mood and affect, thought processes and content, insight, and judgment.

The mental status examination of a patient abruptly confronted with the phobic object will be significant for an anxious affect, with a restricted range. Neurovegetative signs (eg, tremor or diaphoresis) may be present. The patient also reports feeling anxious (mood) and can clearly identify the reason for his/her anxiety (thought content). The thought content is significant for phobic ideation (unrealistic and out-of-proportion fears).

Insight may be impaired, especially during exposure, but in most cases, insight is preserved. Although patients still report that they cannot control their feelings, they also acknowledge that the severity of their fears is not justified.

At any other time, the mental status of a patient with phobic disorder is within normal limits, except for thought content positive for phobic ideation. These phobic ideas may remain undisclosed unless specific questions about phobias are asked. Phobic disorders themselves do not present with suicidal or homicidal ideation, but comorbid conditions commonly associated with them (eg, depression and other anxiety disorders) often do. If comorbid conditions exist, the suicidal and homicidal risk should also be specifically assessed.

Complications

If left untreated, social anxiety disorder or agoraphobia can result in tremendous morbidity. The patient becomes restricted to the most familiar surroundings (eg, a house) or the most trusted people (eg, a family member or spouse), and his or her ability to work and relate to other people is substantially impaired. In addition, there is a considerable risk of substance abuse with this degree of isolation,^[34]and social anxiety disorder has been associated with an increased risk of subsequent depression.^[35]

Specific phobia has been associated with increased risk for suicide attempts and possibly suicidal ideation.^[33]Individuals with this disorder may also be limited by having to avoid buildings (in the case of acrophobia), elevators (in the case of claustrophobia), or even their own lawn (eg, for fear of snakes). As a general rule, less impairment is observed in specific phobia than in social anxiety disorder or agoraphobia.

Differential Diagnoses

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